House
File
2199
-
Introduced
HOUSE
FILE
2199
BY
COMMITTEE
ON
HUMAN
RESOURCES
(SUCCESSOR
TO
HF
656)
(SUCCESSOR
TO
HF
372)
A
BILL
FOR
An
Act
relating
to
continuity
of
care
and
nonmedical
switching
1
by
health
carriers,
health
benefit
plans,
and
utilization
2
review
organizations,
and
including
applicability
3
provisions.
4
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
5
TLSB
2091HZ
(1)
89
ko/rn
H.F.
2199
Section
1.
NEW
SECTION
.
514F.8
Continuity
of
care
——
1
nonmedical
switching.
2
1.
Definitions.
For
the
purpose
of
this
section:
3
a.
“Authorized
representative”
means
the
same
as
defined
in
4
section
514J.102.
5
b.
“Commissioner”
means
the
commissioner
of
insurance.
6
c.
“Cost
sharing”
means
any
coverage
limit,
copayment,
7
coinsurance,
deductible,
or
other
out-of-pocket
expense
8
requirement.
9
d.
“Coverage
exemption”
means
a
determination
made
by
a
10
health
carrier,
health
benefit
plan,
or
utilization
review
11
organization
to
cover
a
prescription
drug
that
is
otherwise
12
excluded
from
coverage.
13
e.
“Coverage
exemption
determination”
means
a
determination
14
made
by
a
health
carrier,
health
benefit
plan,
or
utilization
15
review
organization
whether
to
cover
a
prescription
drug
that
16
is
otherwise
excluded
from
coverage.
17
f.
“Covered
person”
means
the
same
as
defined
in
section
18
514J.102.
19
g.
“Demonstrated
bioavailability”
means
the
same
as
defined
20
in
section
155A.3.
21
h.
“Discontinued
health
benefit
plan”
means
a
covered
22
person’s
existing
health
benefit
plan
that
is
discontinued
by
a
23
health
carrier
during
open
enrollment
for
the
next
plan
year.
24
i.
“Formulary”
means
a
complete
list
of
prescription
drugs
25
eligible
for
coverage
under
a
health
benefit
plan.
26
j.
“Generic
name”
means
the
same
as
defined
in
section
27
155A.3.
28
k.
“Health
benefit
plan”
means
the
same
as
defined
in
29
section
514J.102.
30
l.
“Health
care
professional”
means
the
same
as
defined
in
31
section
514J.102.
32
m.
“Health
care
services”
means
the
same
as
defined
in
33
section
514J.102.
34
n.
“Health
carrier”
means
an
entity
subject
to
the
35
-1-
LSB
2091HZ
(1)
89
ko/rn
1/
9
H.F.
2199
insurance
laws
and
regulations
of
this
state,
or
subject
1
to
the
jurisdiction
of
the
commissioner,
including
an
2
insurance
company
offering
sickness
and
accident
plans,
a
3
health
maintenance
organization,
a
nonprofit
health
service
4
corporation,
a
plan
established
pursuant
to
chapter
509A
5
for
public
employees,
or
any
other
entity
providing
a
plan
6
of
health
insurance,
health
care
benefits,
or
health
care
7
services.
“Health
carrier”
does
not
include
the
department
8
of
human
services,
or
a
managed
care
organization
acting
9
pursuant
to
a
contract
with
the
department
of
human
services
to
10
administer
the
medical
assistance
program
under
chapter
249A
11
or
the
healthy
and
well
kids
in
Iowa
(hawk-i)
program
under
12
chapter
514I.
13
o.
“Interchangeable
biological
product”
means
the
same
as
14
defined
in
section
155A.3.
15
p.
“Nonmedical
switching”
means
a
health
benefit
plan’s
16
restrictive
changes
to
the
health
benefit
plan’s
formulary
17
after
the
current
plan
year
has
begun
or
during
the
open
18
enrollment
period
for
the
upcoming
plan
year,
causing
a
covered
19
person
who
is
medically
stable
on
the
covered
person’s
current
20
prescribed
drug
as
determined
by
the
prescribing
health
care
21
professional,
to
switch
to
a
less
costly
alternate
prescription
22
drug.
23
q.
“Open
enrollment”
means
the
yearly
time
period
during
24
which
an
individual
can
enroll
in
a
health
benefit
plan.
25
r.
“Utilization
review”
means
the
same
as
defined
in
514F.7.
26
s.
“Utilization
review
organization”
means
the
same
as
27
defined
in
514F.7.
28
2.
Nonmedical
switching.
With
respect
to
a
health
carrier
29
that
has
entered
into
a
health
benefit
plan
with
a
covered
30
person
that
covers
prescription
drug
benefits,
all
of
the
31
following
apply:
32
a.
A
health
carrier,
health
benefit
plan,
or
utilization
33
review
organization
shall
not
limit
or
exclude
coverage
of
34
a
prescription
drug
for
any
covered
person
who
is
medically
35
-2-
LSB
2091HZ
(1)
89
ko/rn
2/
9
H.F.
2199
stable
on
such
drug
as
determined
by
the
prescribing
health
1
care
professional,
if
all
of
the
following
apply:
2
(1)
The
prescription
drug
was
previously
approved
by
the
3
health
carrier
for
coverage
for
the
covered
person.
4
(2)
The
covered
person’s
prescribing
health
care
5
professional
has
prescribed
the
drug
for
the
covered
person’s
6
medical
condition
within
the
previous
six
months.
7
(3)
The
covered
person
continues
to
be
an
enrollee
of
the
8
health
benefit
plan.
9
b.
Coverage
of
a
covered
person’s
prescription
drug,
as
10
described
in
paragraph
“a”
,
shall
continue
through
the
last
day
11
of
the
covered
person’s
eligibility
under
the
health
benefit
12
plan,
inclusive
of
any
open
enrollment
period.
13
c.
Prohibited
limitations
and
exclusions
referred
to
in
14
paragraph
“a”
include
but
are
not
limited
to
the
following:
15
(1)
Limiting
or
reducing
the
maximum
coverage
of
16
prescription
drug
benefits.
17
(2)
Increasing
cost
sharing
for
a
covered
prescription
18
drug.
19
(3)
Moving
a
prescription
drug
to
a
more
restrictive
tier
if
20
the
health
carrier
uses
a
formulary
with
tiers.
21
(4)
Removing
a
prescription
drug
from
a
formulary,
unless
22
the
United
States
food
and
drug
administration
has
issued
a
23
statement
about
the
drug
that
calls
into
question
the
clinical
24
safety
of
the
drug,
or
the
manufacturer
of
the
drug
has
25
notified
the
United
States
food
and
drug
administration
of
a
26
manufacturing
discontinuance
or
potential
discontinuance
of
the
27
drug
as
required
by
section
506C
of
the
Federal
Food,
Drug,
and
28
Cosmetic
Act,
as
codified
in
21
U.S.C.
§356c.
29
d.
A
drug
product
with
the
same
generic
name
and
30
demonstrated
bioavailability,
or
an
interchangeable
biological
31
product,
shall
be
considered
equivalent
to
the
prescription
32
drug
prescribed
by
the
covered
person’s
health
care
33
professional.
34
3.
Coverage
exemption
determination
process.
35
-3-
LSB
2091HZ
(1)
89
ko/rn
3/
9
H.F.
2199
a.
To
ensure
continuity
of
care,
a
health
carrier,
health
1
plan,
or
utilization
review
organization
shall
provide
a
2
covered
person
and
prescribing
health
care
professional
3
with
access
to
a
clear
and
convenient
process
to
request
a
4
coverage
exemption
determination.
A
health
carrier,
health
5
plan,
or
utilization
review
organization
may
use
its
existing
6
medical
exceptions
process
to
satisfy
this
requirement.
The
7
process
shall
be
easily
accessible
on
the
internet
site
of
the
8
health
carrier,
health
benefit
plan,
or
utilization
review
9
organization.
10
b.
A
health
carrier,
health
benefit
plan,
or
utilization
11
review
organization
shall
respond
to
a
coverage
exemption
12
determination
request
within
five
calendar
days
of
receipt.
In
13
cases
where
exigent
circumstances
exist,
the
health
carrier,
14
health
benefit
plan,
or
utilization
review
organization
shall
15
respond
within
seventy-two
hours
of
receipt.
If
a
response
by
16
the
health
carrier,
health
benefit
plan,
or
utilization
review
17
organization
is
not
received
within
the
applicable
time
period,
18
the
coverage
exemption
shall
be
deemed
granted.
19
c.
A
coverage
exemption
shall
be
expeditiously
granted
for
a
20
discontinued
health
benefit
plan
if
a
covered
person
enrolls
in
21
a
comparable
plan
offered
by
the
same
health
carrier,
and
all
22
of
the
following
conditions
apply:
23
(1)
The
covered
person
is
medically
stable
on
a
prescription
24
drug
as
determined
by
the
prescribing
health
care
professional.
25
(2)
The
prescribing
health
care
professional
continues
26
to
prescribe
the
drug
for
the
covered
person
for
the
covered
27
person’s
medical
condition.
28
(3)
In
comparison
to
the
discontinued
health
benefit
plan,
29
the
new
health
benefit
plan
does
any
of
the
following:
30
(a)
Limits
or
reduces
the
maximum
coverage
of
prescription
31
drug
benefits.
32
(b)
Increases
cost
sharing
for
the
prescription
drug.
33
(c)
Moves
the
prescription
drug
to
a
more
restrictive
tier
34
if
the
health
carrier
uses
a
formulary
with
tiers.
35
-4-
LSB
2091HZ
(1)
89
ko/rn
4/
9
H.F.
2199
(d)
Excludes
the
prescription
drug
from
the
health
benefit
1
plan’s
formulary.
2
d.
Upon
granting
of
a
coverage
exemption
for
a
drug
3
prescribed
by
a
covered
person’s
prescribing
health
care
4
professional,
a
health
carrier,
health
benefit
plan,
or
5
utilization
review
organization
shall
authorize
coverage
no
6
more
restrictive
than
that
offered
in
a
discontinued
health
7
benefit
plan,
or
than
that
offered
prior
to
implementation
of
8
restrictive
changes
to
the
health
benefit
plan’s
formulary
9
after
the
current
plan
year
began.
10
e.
If
a
determination
is
made
to
deny
a
request
for
a
11
coverage
exemption,
the
health
carrier,
health
benefit
plan,
12
or
utilization
review
organization
shall
provide
the
covered
13
person
or
the
covered
person’s
authorized
representative
and
14
the
authorized
person’s
prescribing
health
care
professional
15
with
the
reason
for
denial
and
information
regarding
the
16
procedure
to
appeal
the
denial.
Any
determination
to
deny
a
17
coverage
exemption
may
be
appealed
by
a
covered
person
or
the
18
covered
person’s
authorized
representative.
19
f.
A
health
carrier,
health
benefit
plan,
or
utilization
20
review
organization
shall
uphold
or
reverse
a
determination
to
21
deny
a
coverage
exemption
within
five
calendar
days
of
receipt
22
of
an
appeal
of
denial.
In
cases
where
exigent
circumstances
23
exist,
a
health
carrier,
health
benefit
plan,
or
utilization
24
review
organization
shall
uphold
or
reverse
a
determination
to
25
deny
a
coverage
exemption
within
seventy-two
hours
of
receipt.
26
If
the
determination
to
deny
a
coverage
exemption
is
not
upheld
27
or
reversed
on
appeal
within
the
applicable
time
period,
the
28
denial
shall
be
deemed
reversed
and
the
coverage
exemption
29
shall
be
deemed
approved.
30
g.
If
a
determination
to
deny
a
coverage
exemption
is
31
upheld
on
appeal,
the
health
carrier,
health
benefit
plan,
32
or
utilization
review
organization
shall
provide
the
covered
33
person
or
the
covered
person’s
authorized
representative
and
34
the
covered
person’s
prescribing
health
care
professional
with
35
-5-
LSB
2091HZ
(1)
89
ko/rn
5/
9
H.F.
2199
the
reason
for
upholding
the
denial
on
appeal
and
information
1
regarding
the
procedure
to
request
external
review
of
the
2
denial
pursuant
to
chapter
514J.
Any
denial
of
a
request
for
a
3
coverage
exemption
that
is
upheld
on
appeal
shall
be
considered
4
a
final
adverse
determination
for
purposes
of
chapter
514J
and
5
is
eligible
for
a
request
for
external
review
by
a
covered
6
person
or
the
covered
person’s
authorized
representative
7
pursuant
to
chapter
514J.
8
4.
Limitations.
This
section
shall
not
be
construed
to
do
9
any
of
the
following:
10
a.
Prevent
a
health
care
professional
from
prescribing
11
another
drug
covered
by
the
health
carrier
that
the
health
care
12
professional
deems
medically
necessary
for
the
covered
person.
13
b.
Prevent
a
health
carrier
from
doing
any
of
the
following:
14
(1)
Adding
a
prescription
drug
to
its
formulary.
15
(2)
Removing
a
prescription
drug
from
its
formulary
if
the
16
drug
manufacturer
has
removed
the
drug
for
sale
in
the
United
17
States.
18
5.
Enforcement.
The
commissioner
may
take
any
enforcement
19
action
under
the
commissioner’s
authority
to
enforce
compliance
20
with
this
section.
21
Sec.
2.
APPLICABILITY.
This
Act
applies
to
a
health
benefit
22
plan
that
is
delivered,
issued
for
delivery,
continued,
or
23
renewed
in
this
state
on
or
after
January
1,
2023.
24
EXPLANATION
25
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
26
the
explanation’s
substance
by
the
members
of
the
general
assembly.
27
This
bill
relates
to
the
continuity
of
care
for
a
covered
28
person
and
nonmedical
switching
by
health
carriers,
health
29
benefit
plans,
and
utilization
review
organizations.
30
The
bill
defines
“nonmedical
switching”
as
a
health
benefit
31
plan’s
restrictive
changes
to
the
health
benefit
plan’s
32
formulary
after
the
current
plan
year
has
begun
or
during
the
33
open
enrollment
period
for
the
upcoming
plan
year,
causing
a
34
covered
person
who
is
medically
stable
on
the
covered
person’s
35
-6-
LSB
2091HZ
(1)
89
ko/rn
6/
9
H.F.
2199
current
prescribed
drug
as
determined
by
the
prescribing
1
health
care
professional,
to
switch
to
a
less
costly
alternate
2
prescription
drug.
“Health
benefit
plan”,
“health
carrier”,
3
and
“utilization
review
organization”
are
also
defined
in
the
4
bill.
5
The
bill
provides
that
during
a
covered
person’s
eligibility
6
under
a
health
benefit
plan,
inclusive
of
any
open
enrollment
7
period,
a
health
plan
carrier,
health
benefit
plan,
or
8
utilization
review
organization
shall
not
limit
or
exclude
9
coverage
of
a
prescription
drug
for
the
covered
person
if
the
10
covered
person
is
medically
stable
on
the
drug
as
determined
11
by
the
prescribing
health
care
professional,
the
drug
was
12
previously
approved
by
the
health
carrier
for
coverage
for
13
the
person,
and
the
covered
person’s
prescribing
health
care
14
professional
has
prescribed
the
drug
for
the
person’s
medical
15
condition
within
the
previous
six
months.
The
bill
includes,
16
as
prohibited
limitations
or
exclusions,
reducing
the
maximum
17
coverage
of
prescription
drug
benefits,
increasing
cost
sharing
18
for
a
covered
drug,
moving
a
drug
to
a
more
restrictive
tier,
19
and
removing
a
drug
from
a
formulary.
A
prescription
drug
20
may,
however,
be
removed
from
a
formulary
if
the
United
States
21
food
and
drug
administration
issues
a
statement
regarding
the
22
clinical
safety
of
the
drug,
or
the
manufacturer
of
the
drug
23
notifies
the
United
States
food
and
drug
administration
of
a
24
manufacturing
discontinuance
or
potential
discontinuance
of
the
25
drug
as
required
by
section
506c
of
the
Federal
Food,
Drug,
26
and
Cosmetic
Act.
The
bill
provides
that
a
drug
product
with
27
the
same
generic
name
and
demonstrated
bioavailability,
or
an
28
interchangeable
biological
product,
is
considered
equivalent
to
29
the
prescription
drug
prescribed
by
the
covered
person’s
health
30
care
professional.
31
The
bill
requires
a
covered
person
and
prescribing
health
32
care
professional
to
have
access
to
a
process
to
request
a
33
coverage
exemption
determination.
The
bill
defines
“coverage
34
exemption
determination”
as
a
determination
made
by
a
35
-7-
LSB
2091HZ
(1)
89
ko/rn
7/
9
H.F.
2199
health
carrier,
health
benefit
plan,
or
utilization
review
1
organization
whether
to
cover
a
prescription
drug
that
is
2
otherwise
excluded
from
coverage.
3
A
coverage
exemption
determination
request
must
be
approved
4
or
denied
by
the
health
carrier,
health
benefit
plan,
or
5
utilization
review
organization
within
five
calendar
days,
6
or
within
72
hours
if
exigent
circumstances
exist.
If
a
7
determination
is
not
received
within
the
applicable
time
period
8
the
coverage
exemption
is
deemed
granted.
9
The
bill
requires
a
coverage
exemption
to
be
expeditiously
10
granted
for
a
health
benefit
plan
that
is
discontinued
for
the
11
next
plan
year
if
a
covered
person
enrolls
in
a
comparable
12
plan
offered
by
the
same
health
carrier,
and
in
comparison
13
to
the
discontinued
health
benefit
plan,
the
new
health
14
benefit
plan
limits
or
reduces
the
maximum
coverage
for
a
15
prescription
drug,
increases
cost
sharing
for
the
prescription
16
drug,
moves
the
prescription
drug
to
a
more
restrictive
17
tier,
or
excludes
the
prescription
drug
from
the
formulary.
18
If
a
coverage
exemption
is
granted,
the
bill
requires
an
19
authorization
of
coverage
that
is
no
more
restrictive
than
20
that
offered
in
the
discontinued
health
benefit
plan,
or
than
21
that
offered
prior
to
implementation
of
restrictive
changes
22
to
the
health
benefit
plan’s
formulary
after
the
current
plan
23
year
began.
If
a
determination
is
made
to
deny
a
request
for
24
a
coverage
exemption,
the
reason
for
denial
and
the
procedure
25
to
appeal
the
denial
must
be
provided
to
the
requestor.
Any
26
determination
to
deny
a
coverage
exemption
may
be
appealed
to
27
the
health
carrier,
health
benefit
plan,
or
utilization
review
28
organization.
A
determination
to
uphold
or
reverse
denial
29
of
a
coverage
exemption
must
be
made
within
five
calendar
30
days
of
receipt
of
an
appeal,
or
within
72
hours
if
exigent
31
circumstances
exist.
If
a
determination
is
not
made
within
the
32
applicable
time
period,
the
denial
is
deemed
reversed
and
the
33
coverage
exemption
is
deemed
approved.
34
If
a
determination
to
deny
a
coverage
exemption
is
upheld
on
35
-8-
LSB
2091HZ
(1)
89
ko/rn
8/
9
H.F.
2199
appeal,
the
reason
for
upholding
the
denial
and
the
procedure
1
to
request
external
review
of
the
denial
pursuant
to
Code
2
chapter
514J
must
be
provided
to
the
individual
who
filed
the
3
appeal.
Any
denial
of
a
request
for
a
coverage
exemption
that
4
is
upheld
on
appeal
is
considered
a
final
adverse
determination
5
for
purposes
of
Code
chapter
514J
and
is
eligible
for
a
request
6
for
external
review
by
a
covered
person
or
the
covered
person’s
7
authorized
representative
pursuant
to
Code
chapter
514J.
8
The
bill
shall
not
be
construed
to
prevent
a
health
care
9
professional
from
prescribing
another
drug
covered
by
the
10
health
carrier
that
the
health
care
professional
deems
11
medically
necessary
for
the
covered
person.
12
The
bill
shall
not
be
construed
to
prevent
a
health
carrier
13
from
adding
a
drug
to
its
formulary,
or
from
removing
a
drug
14
from
its
formulary
if
the
drug
manufacturer
removes
the
drug
15
for
sale
in
the
United
States.
16
The
bill
allows
the
commissioner
to
take
any
necessary
17
enforcement
action
under
the
commissioner’s
authority
to
18
enforce
compliance
with
the
bill.
19
The
bill
is
applicable
to
health
benefit
plans
that
are
20
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
21
state
on
or
after
January
1,
2023.
22
-9-
LSB
2091HZ
(1)
89
ko/rn
9/
9